Dr Alan M Campion NewApproachComprehensive Report ... · •...

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Inadequate –––

Are services safe? Inadequate –––

Are services effective? Requires improvement –––

Are services caring? Requires improvement –––

Are services responsive to people’s needs? Requires improvement –––

Are services well-led? Inadequate –––

DrDr AlanAlan MM CampionCampionQuality Report

New Mill Street Surgery1 Wolseley StreetLondonSE1 2BPTel: 020 7252 1817Website: www.newmillstreet.com

Date of inspection visit: 9 November 2017Date of publication: 28/12/2017

1 Dr Alan M Campion Quality Report 28/12/2017

Contents

PageSummary of this inspectionOverall summary 2

The six population groups and what we found 4

Detailed findings from this inspectionOur inspection team 5

Background to Dr Alan M Campion 5

Detailed findings 6

Action we have told the provider to take 21

Overall summaryLetter from the Chief Inspector of GeneralPractice

This practice is rated as Inadequate overall. Thepractice was previously inspected on 28 April 2015when the practice was rated as good overall.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – requires improvement

Are services caring? – requires improvement

Are services responsive? – requires improvement

Are services well-led? - Inadequate

As part of our inspection process, we also look at thequality of care for specific population groups. Theconcerns raised in Safe Caring and Well Led affect all ofthe population groups. The population groups are ratedas:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired andstudents – Inadequate

People whose circumstances may make them vulnerable– Inadequate

People experiencing poor mental health (includingpeople with dementia) - Inadequate

We carried out an announced comprehensive at Dr AlanM Campion on 9 November 2017 as part of our inspectionprogramme.

At this inspection we found:

• The practice had not taken action to assess ormitigate risks associated with fire, infection controllegionella or health and safety.

• Safeguarding policies were not practice specific,non-clinical staff had not received safeguardingtraining and not all staff were chaperoning inaccordance with current legislation and guidance.

• There was limited evidence of learning fromsignificant events and no policy in place. Thecomplaints process also did not function effectively.

• There was no evidence that the practice was takingaction in response to patient safety alerts inaccordance with their policy and there was noeffective system in place for monitoring urgentdiagnostic referrals.

• Medicines were not managed effectively. Thepractice could not locate Patient Group Directions(PGDs) for nursing staff and we found two expiredmedicines in the practice fridges.

Summary of findings


• Not all staff had undertaken the required trainingand systems for recruitment and appraisals wereineffective or non-existent.

• The care plans we reviewed indicated that thepractice was delivering treatment in accordance withcurrent guidelines and best practice and we sawsome evidence of worked which aimed to improvethe quality of care provision. However, the practiceachieved lower than the local and national averagesin respect of a number of clinical and public healthindicators. There was limited evidence of actiontaken to review below average performance andmake improvements.

• Feedback from patients on the day of the inspectionindicated that staff treated patients withcompassion, kindness, dignity and respect. However,national patient survey scores showed the practiceperformed below local and national averages inrespect of its GP consultations and satisfaction withreception staff.

• Most patients spoken to on the day of the inspectionfound the appointment system easy to use andreported that they were able to access care whenthey needed it. However, some patients told us thatthey had to wait a long time to be seen when theyarrived for their appointment. The national patientsurvey showed the practice scored lower than otherson questions related to access.

• Practice policies were not effective. Some policieswere from other services and/or did not containrequired information on leadership and governancearrangements. There was no evidence of internalmeetings having taken place since January 2016.

The areas where the provider must make improvementsare:

• Establish effective systems and processes to ensuregood governance in accordance with thefundamental standards of care.

• Ensure sufficient numbers of suitably qualified,competent, skilled and experienced persons aredeployed to meet the fundamental standards of careand treatment.

• Ensure care and treatment is provided in a safe wayto patients.

• Ensure patients are protected from abuse andimproper treatment.

• Ensure persons employed in the provision of theregulated activity receive the appropriate support,training, professional development, supervision andappraisal necessary to enable them to carry out theduties.

• Ensure recruitment procedures are established andoperated effectively to ensure only fit and properpersons are employed.

The areas where the provider should makeimprovements are:

• Consider ways to highlight bereavement andtranslation services.

• Continue with planned work to upgrade the practicepremises.

I am placing this service in special measures.Services placed in special measures will bereinspected after a period of six months.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older people Inadequate –––

People with long term conditions Inadequate –––

Families, children and young people Inadequate –––

Working age people (including those recently retired andstudents)

Inadequate –––

People whose circumstances may make them vulnerable Inadequate –––

People experiencing poor mental health (including peoplewith dementia)


Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC lead inspector.The team included a GP specialist adviser and an expertby experience.

Background to Dr Alan MCampionDr Alan M Campion is part of Southwark CCG and serves5200 patients. The practice is registered with the CQC forthe following regulated activities Diagnostic and screeningprocedures; Treatment of disease, disorder or injury;Maternity and midwifery services.

The practice is located within an area ranked on the thirdleast deprived decile on the index of multiple deprivation.The area has a high level of unemployment compared tothe local and national average. The patient list consists of alower proportion of older people and children compared toother areas in the country and a significantly higherproportion of working patients.

The practice is run by Dr Alan Campion. There is a salariedGP and a long term locum. Doctors at the practicecollective provide 16 sessions per week. There is a part timepractice nurse working 35 hours per week, another nurse(currently absent) who works 37.5 hours per week and a fulltime healthcare assistant. The practice has employedlocum nursing cover for 8 hours per week while the nursewas absent. The practice is a teaching practice for final yearmedical students.

We were told by staff that the practice manager worked inthe practice between one and two days per month. Thisstaff member dealt with financing, staff recruitment andengagement with external partners including NHS Englandand the CCG. Managerial responsibilities were dividedbetween other members of staff including some employedthrough the federation, the patient services manager andthe practice nurse.

The practice opens at 7.30 am Monday to Friday. Thepractice closes at 8pm on Monday and Tuesday and 6.30pm the rest of the week.

The Dr Alan M Campion service operates from New MillStreet Surgery, London, Southwark, SE12BP which is aproperty rented from a private landlord. The premises arenot suited to accommodating persons with disabilities butwe were told that the practice had obtained animprovement grant to make appropriate adjustments.

Practice patients are directed to contact the local out ofhours provider when the surgery is closed.

The practice operates under a Personal Medical Services(PMS) contract, and is signed up to a number of local andnational enhanced services (enhanced services require anenhanced level of service provision above what is normallyrequired under the core GP contract). These are: ChildhoodVaccination and Immunisation Scheme, Extended HoursAccess, Facilitating Timely Diagnosis and Support forPeople with Dementia, Influenza and PneumococcalImmunisations, Learning Disabilities, Patient Participation,Rotavirus and Shingles Immunisation, Services for ViolentPatients, Unplanned Admissions.

The practice part of a GP federation Quay Health Solutions.

DrDr AlanAlan MM CampionCampionDetailed findings


Our findingsThe practice was rated as inadequate for providingsafe services.

Safety systems and processes

The practice did not have a clear system to ensure patientswere safe or safeguarded from abuse.

• The systems in place to safeguard children andvulnerable adults from abuse were not specific to thepractice. For example the child safeguarding policystated that the staff responsible for record keeping wasa person unknown to the practice. The adultsafeguarding policy related to safeguarding for the localextended primary care service. The practice providedupdated policies after our inspection but the adultsafeguarding policy did not explicitly state who thepractice lead was.

• We saw several instances where the practice had raisedconcerns with other agencies to support patients andprotect them from neglect and abuse. The practice saidthat they did not have regular meetings with the healthvisitor and there was no documented evidence ofmeetings taking place. We were told this was due to alack of availability among the health visitor team withinthe locality.

• The practice had not carried out staff checks, includingchecks of professional registration where relevant, onrecruitment and on an ongoing basis. Disclosure andBarring Service (DBS) checks had not been undertakenfor two members of clinical staff; though we saw thatthese were requested on 8 November 2017. (DBS checksidentify whether a person has a criminal record or is onan official list of people barred from working in roleswhere they may have contact with children or adultswho may be vulnerable). The medical indemnity on filefor one of the locum GPs had expired and there was noevidence of indemnity insurance for the locum nursingstaff though we were told after the inspection indemnitycover would be provided by the nurse’s unions.

• Not all staff had received up-to-date safeguarding andsafety training appropriate to their role. None of thenon-clinical staff had any safeguarding training. All staffspoken to said they were alert to signs of abuse andknew how to report concerns. Staff who acted as

chaperones were trained for the role and had received aDBS check; however, one staff member told us that theywould only stand within the curtain so they could seethe examination if a clinician requested them to do so.The practice’s chaperone policy was from anotherorganisation.

• The practice ensured that clinical equipment andelectrical equipment were safe and regularly tested.There were systems for safely managing healthcarewaste.

Risks to patients

The systems to assess, monitor and manage risks to patientsafety were ineffective.

• The arrangements in place for planning and monitoringthe number and mix of staff needed did not ensuresufficient staff were employed to provide effectivemanagerial oversight of the practice and providesufficient nursing time. We were told that the practicemanager only attended the practice once or twice permonth. A list provided showed the division ofmanagerial responsibility within the practice but it wasevident that this was not effective. For example, despiteasking the people designated as responsible for thisarea, we were unable to find recruitment files for all staffmembers on the day ofthe inspection. The practice’srecruitment policy was from another practice.

• Staff understood their responsibilities to manageemergencies on the premises and to recognise those inneed of urgent medical attention. Clinicians knew howto identify and manage patients with severe infections.For example we were given an example of how staffresponded to a patient who presented with sepsis.However, from looking at records the practice’semergency equipment was not being reviewedconsistently.

• It was evident that the impact to staffing changes waseither not fully assessed or addressed. We were told thatthe practice manager had not been working full time atthe practice for a number of years and it was evidentthat in a number of key areas there was a lack ofmanagerial control. The practice produced a documentwhich reviewed a number of inefficiencies and it wasapparent that the impact of not having effectivemanagement was known but had not been addressed.The practice employed two nurses. We were told that

Are services safe?



one of the full time nurses was on sick leave at the timeof our inspection. The remaining nurse was assisted by alocum nurse who provided eight hours of nursing timeper week. The locum nurse was the only nurse whoadministered childhood immunisations. In spite of areduction in nursing hours the practice nurse had beentasked with being the lead for both complaints andsignificant events and accepted that they were not ableto effectively oversee these areas due to the practicenursing commitments.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe careand treatment to patients yet there was no clear failsafesystem in place for urgent referrals.

• Referral letters included all of the necessaryinformation. However, there was no systematicapproach to checking that a patient had attendedsecondary care for urgent diagnostics.

• Individual care records were written and managed in away that kept patients safe. The care records we sawshowed that information needed to deliver safe careand treatment was available to relevant staff in anaccessible way.

• The practice had systems for sharing information withstaff and other agencies to enable them to deliver safecare and treatment.

Safe and appropriate use of medicines

The systems in place did not ensure that medicines werehandled safely.

• Prescription stationery was kept securely and there wasa system for monitoring the collection of controlled drugprescriptions. However, there was no log to monitor theuse of other prescriptions. Uncollected prescriptionswere not checked with sufficient frequency. Receptionstaff told us that uncollected prescriptions would bechecked every two to three months. We found a numberof uncollected prescriptions dating back to August 2017.

• The systems in place to monitor vaccines in the practicewere not effective as we found expired vitamin K andmeningococcal vaccines which had expired in October2017. We were told that the vitamin K was theresponsibility of the visiting midwifery team.

• Staff at the practice were unable to locate Patient GroupDirections (PGDs) for the practice nurse and the many ofthe ones provided for the locum nurse had expired. Wewere told that staff had sight of these prior to theinspection but they could not find them. We wereprovided with up to date PGDs for the salaried nurseafter the inspection but did not receive those for thelocum nurse.

• Practice prescribing of quinolones and cephalosporinswas twice the national average.

• Staff prescribed, administered or supplied medicines topatients and gave advice on medicines in line with legalrequirements and current national guidance. Thepractice had audited antimicrobial prescribing. Therewas evidence of actions taken to support goodantimicrobial stewardship; for example, an auditundertaken with the local medicines management teamregarding the prescribing of antibiotics for urinary tractinfections. The first cycle of the audit showed that thepractice had not met the 90% compliance standardacross three criteria. However, the information providedindicated that this was because of the high proportionof patients who required antibiotics for lower urinarytract infections. The practice considered longer coursesand different antibiotics to be more effective in treatingthese infections. The lead GP had contacted a professorwho run specialist clinics for the treatment of urinarytract infections for further advice in this area.

• Patients’ health was monitored to ensure medicineswere being used safely and followed up onappropriately. The practice involved patients in regularreviews of their medicines.

Track record on safety

The practice did not have safety systems in place tomanage risk.

• The practice produced a fire safety risk assessment. Thiswas on a single sheet of paper and was notcomprehensive, not dated and did not include an actionplan to address the risk identified. We saw evidence ofan email from an external organisation who confirmedthat they would undertake a range of risk assessmentsincluding fire safety and legionella on 15 November2017. The practice did not have a significant event policyand other policies contained incorrect information. Forexample we were told that the nurse was the infection

Are services safe?



control lead by most members of staff, though the nurseherself was uncertain if she fulfilled this role and was notactively undertaking infection control leadership duties.The policy for infection control stated responsibility wassplit between the lead GP and the practice manager.Staff were working to different infection control policies.No infection control audit had been undertaken in atleast the last 12 months.We saw evidence that thepractice had instructed an external company toundertake a range of risk assessments, includinglegionella and fire safety, on 15 September 2017 andwere provided with copies of these after our inspectionwhich included action plans. There was no evidence offire drills, no fire policy and we were told that staff didnot know how to test the fire alarm which only coveredthe second floor of the premises.

Lessons learned and improvements made

Learning from significant events was not clear though wesaw example of improvements made in response to oneevent and there was no clear system in place for acting onpatient safety alerts that staff could tell us about on the dayof the inspection.

• There was no policy in place for the management ofsignificant events. There was a recording form availableand some staff knew where to access this but we wereinformed by one of the GPs that this form was notalways used and noted that other events had beenrecorded using different means. It was unclear who wasresponsible for documenting significant events fromdiscussions with staff. The lead for significant eventstold us that they were trying to get staff to documentevents they identified. One staff member was unclear as

to what constituted a significant event and said theywere not involved in significant event management. Allother staff we spoke with were aware of one recentevent but only some staff could outline action taken orthe learning from this. One of the clinical staff memberswas able to identify a significant event regarding anallergic reaction to medication and concerns wereshared with the local medicines management team.Reference to discussion regarding significant events wasrecorded on the significant event forms.

• There were no minutes from meetings where significantevents were discussed and learning shared. We weretold of one incident related to childhood immunisationswhich resulted in the practice’s new patient form beingupdated.

• The practice had a policy for reviewing patient safetyalerts. The policy stated that these should be discussedand action taken and documented. There was a safetyalert log on the practice’s computer system. This onlyhad one patient safety alert noted from January 2017.One clinical staff member could outline action taken inresponse to a recent medicines alert. This was not notedon the safety alert log and there were no other alertsrecorded as having been reviewed or action taken. Wewere told by staff that alerts were managed by apharmacist employed by the federation. We wereprovided with an alert monitoring spreadsheet from thefederation after the inspection. This did not containinformation about action taken in response to alerts butonly confirmed that the practice had eitheracknowledged receipt of the alert or that the alert didnot apply to the practice.

Are services safe?



Our findingsWe rated the practice as requires improvement forproviding effective services overall and across allpopulation groups.

Effective needs assessment, care and treatment

We saw that clinicians assessed needs and delivered careand treatment in line with current legislation, standardsand guidance. However, practice specific clinical pathwaysand protocols were lacking in respect of the managementof pathology results and letters and urgent referrals. Therewas no evidence of updates to guidance being discussed inclinical meetings.

• Patients’ needs were fully assessed. This included theirclinical needs and their mental and physical wellbeing.

• The percentage of antibiotic items prescribed that arecephalosporins or quinolones was 10% compared with4% in the CCG and 5% nationally.

• We saw no evidence of discrimination when makingcare and treatment decisions.

• The practice used a clinical system which aimed toensure compliance with the latest prescribingguidelines and that patients were placed on appropriatereferral pathways. The practice also made use of an appwhich enabled them to access advice from consultants.Virtual clinics were held for a number of long termconditions. These were supported by consultants fromlocal secondary care services who aimed to ensure thatcare and treatment for patient with complex long termconditions was optimised.

• Staff advised patients what to do if their condition gotworse and where to seek further help and support.

Older people:

• The practice participated in a holistic health assessmentscheme for patients who were over 80, over 65 who hadnot attended the GP in some time or who hadcomorbidities or frailties. Patients were provided with afull assessment of their physical, mental and socialneeds. Care plans were drafted and referrals were madeto relevant health and social care organisations. Those

identified as being frail had a clinical review including areview of medication. The practice delivered eightassessments at home and 51 within the practice in thelast year.

• The practice administered influenza immunisations to76% of patients over 65.

• The practice followed up on older patients dischargedfrom hospital. It ensured that their care plans andprescriptions were updated to reflect any extra orchanged needs.

People with long-term conditions:

• The practice had achieved their locality targets fordiabetes and were the second best performing practicefor diabetes within the CCG in 2016/17.

• Patients with other long-term conditions had astructured annual review to check their health andmedicines needs were being met. For patients with themost complex needs, the GP worked with other healthand care professionals to deliver a coordinated packageof care. However, the percentage of patients with COPDwho had a review, undertaken by a healthcareprofessional, including an assessment of breathlessnessusing the Medical Research Council dyspnoea scale inthe preceding 12 months was 77% compared with thelocal average 91% and the national average of 90%. Theexception reporting rate for this indicator was 2%compared with 3% in the CCG and 9% nationally.

• The practice had fitted 25 ambulatory blood pressuremonitors in 2016/17.

• Staff who were responsible for reviews of patients withlong term conditions had received specific training.

Families, children and young people:

• Childhood immunisations were carried out in line withthe national childhood vaccination programme. Uptakerates for the vaccines given were below with the targetpercentage of 90% for children under 1 receiving the fullcourse of recommended vaccines (80%), children agedtwo who had received the pneumococcal conjugatebooster vaccine (86%) and children aged two withHaemophilus influenza type b and Meningitis C boostervaccines (86%). The practice told us that this was due topatients having vaccines administered privately or beingunwilling to vaccinate their child due to concerns

Are services effective?(for example, treatment is effective)

Requires improvement –––


around the MMR vaccine. Childhood immunisationswere usually administered by a staff member currentlyon long term sick leave. Only the locum nurse workingeight hours per week currently administered childhoodimmunisations. However the practice could referchildren to the local extended access hub to haveimmunisations administered.

Working age people (including those recently retired andstudents):

• The practice’s uptake for cervical screening was 68%,which was below the 80% coverage target for thenational screening programme. We were told that thelower than average rate of cervical screening was as aresult of a reduction in nursing staff, and that manypatients have screening done privately but then do notinform the practice of the results. The practice told usthat they had undertaken a text message campaign torecall all women who had not attended for screeningand offered these women weekend appointments at theextended access hub.

• The practice had systems to inform eligible patients tohave the meningitis vaccine.

• Patients had access to appropriate health assessmentsand checks including NHS checks for patients aged40-74. There was appropriate follow-up on the outcomeof health assessments and checks where abnormalitiesor risk factors were identified. The practice hadundertaken 216 health checks in the last year.

People whose circumstances make them vulnerable:

• End of life care was delivered in a coordinated waywhich took into account the needs of those whosecircumstances may make them vulnerable.

• The practice held a register of patients living invulnerable circumstances including those with alearning disability.

People experiencing poor mental health (including peoplewith dementia):

• The practice had undertaken screening for 157 patientsat risk of dementia in the previous year.

• The percentage of patients diagnosed with dementiawhose care plan has been reviewed in a face-to-facereview in the preceding 12 months was 88% comparedwith the local 84% and the national average of 84%

nationally. However, the exception reporting rate was33% compared with the local average 5% and thenational average of 7%. The practice was unable toaccount for this.

• 87% of patients diagnosed with schizophrenia, bipolaraffective disorder and other psychoses had acomprehensive, agreed care plan documented in theprevious 12 months. This was comparable to thenational average of 90%. Exception reporting was 2.6%,lower than the national average of 12.5%.

• The practice considered the physical health needs ofpatients with poor mental health and those living withdementia. Though the percentage of patientsexperiencing poor mental health who had receiveddiscussion and advice about alcohol consumption waslower than the local and national average (68%compared with 91% in the CCG and 91% nationally), thepractice had not exception reported any patient underthis criteria compared to 6% in the CCG and 10%nationally.

Monitoring care and treatment

The practice had a programme of quality improvementactivity and we saw some limited evidence of qualityimprovement. Where appropriate, clinicians took part inlocal and national improvement initiatives including localprescribing audits.

The most recent published Quality Outcome Framework(QOF) results were 97% of the total number of pointsavailable compared with the clinical commissioning group(CCG) average of 94% and national average of 96%. Theoverall exception reporting rate was 4.4% compared with anational average of 10%. (QOF is a system intended toimprove the quality of general practice and reward goodpractice. Exception reporting is the removal of patientsfrom QOF calculations where, for example, the patientsdecline or do not respond to invitations to attend a reviewof their condition or when a medicine is not appropriate.)

The practice performed well in respect of management ofblood pressure in patients with diabetes with 91% of thesepatients having well controlled blood pressure comparedto the local average of 77% and the national average of78%. The practice provided a list of indicators whichshowed that their performance for diabetic indicators wasthe second highest within the CCG.




However the percentage of patients with schizophrenia,bipolar affective disorder and other psychoses who have arecord of alcohol consumption in the preceding 12 monthswas 68% compared with 91% in the CCG and 91%nationally. The practice had not exception reported anypatient under this criteria compared to 6% in the CCG and10% nationally. The practice attributed this to a problemwith coding though this was not support with any analysis.

The percentage of patients with COPD who have had areview, undertaken by a healthcare professional, includingan assessment of breathlessness using the MedicalResearch Council dyspnoea scale in the preceding 12months was 77% compared with the local average 91% andthe national average of 90%. The exception reporting ratefor this indicator was 2% compared with 3% in the CCG and9% nationally. The practice told that a large number oftheir patients refused to come into the practice for theirannual review and some patients have been seen insecondary care but not had their score on the dyspnoeascale recorded. The practice told us that they haddiscussed these concerns during a virtual clinic with thelocal hospital.

The percentage of patients diagnosed with dementiawhose care plan has been reviewed in a face-to-face reviewin the preceding 12 months was 88% compared with thelocal 84% and the national average of 84% nationally.However, the exception reporting rate was 33% comparedwith the local average 5% and the national average of 7%.Again the practice could not explain why performance inthis area deviated from the local and national averages.The practice informed us after the inspection that they had12 patients with dementia and four of these patients intotal had been exception reported. Three of these patientswere exception reported on the basis that the date ofdiagnosis was within the last three months.

The practice performed in line with other practice for allother QOF indicators.

The practice used information about care and treatment tomake improvements.

• An audit was undertaken of patients with chronicobstructive pulmonary disease (COPD) with a view toimproving the quality of reviews of these patients. Theaudit demonstrated some improvement in two areas.The number of patients prescribed a metered doseinhaler who had also been issued a spacer (device

which assists medicine from inhalers to reach the lungs)increased from 23% at the first cycle to 28% in thesecond cycle. The percentage of patients who had acheck of their inhaler technique increased from 25% to42%. The practice participated in virtual clinics whichreviewed patients with atrial fibrillation who were notprescribed anticoagulant medicine. Of the 17 patientsreviewed an additional four patients were prescribed ananticoagulant. The rest of the patients either refusedintervention or were not suitable for anticoagulation.

Effective staffing

Staff had the clinical skills, knowledge and experience tocarry out their roles. For example, staff whose role includedimmunisations and taking samples for the cervicalscreening programme had received specific training andcould demonstrate how they stayed up to date. However,some essential training had not been completed.

• Though there was evidence of clinical updates beingundertaken, for example in respect of the managementof long term conditions, there were gaps in essentialtraining. For example no non-clinical staff member hadcompleted basic life support training within the last 12months. All of the non-clinical staff whose files wereviewed had no record of safeguarding training and thetraining matrix provided by the practice indicated thatno non-clinical staff had received this training.Non-clinical staff whose files we reviewed had either notcompleted any information governance training or thishad not been done within the last 12 months. Thiscorresponded with the information in the training matrixprovided.

• All staff we spoke with said that the leadership withinthe practice was supportive and staff were allowed toattend any training that they requested. However, therewas no evidence of an induction process or regularone-to-one meetings and appraisals.

• We were told that coaching and mentoring, clinicalsupervision and support for revalidation were offered.

• The healthcare assistant had the requisite trainingwhich included the requirements of the Care Certificate.

• Due to a lack of effective leadership around staffing andrecruitment there was no clear approach for supportingand managing staff when their performance was poor orvariable.




Coordinating care and treatment

Staff worked together and with other health and social careprofessionals to deliver effective care and treatment.

• We saw records that showed that all appropriate staff,including those in different teams, services andorganisations, were involved in assessing, planning anddelivering care and treatment.

• Patients received coordinated and person-centred care.This included when they moved between services, whenthey were referred, or after they were discharged fromhospital. The practice worked with patients to developpersonal care plans that were shared with relevantagencies.

• The practice ensured that end of life care was deliveredin a coordinated way which took into account the needsof different patients, including those who may bevulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients tolive healthier lives.

• The practice identified patients who may be in need ofextra support and directed them to relevant services.This included patients in the last 12 months of theirlives, patients at risk of developing a long-termcondition and carers.

• Staff encouraged and supported patients to be involvedin monitoring and managing their health.

• Staff discussed changes to care or treatment withpatients and their carers as necessary.

• The practice supported national priorities and initiativesto improve the population’s health, for example, stopsmoking campaigns, alcohol risk reduction.

Consent to care and treatment

The practice obtained consent to care and treatment in linewith legislation and guidance.

• Clinicians understood the requirements of legislationand guidance when considering consent and decisionmaking.

• Clinicians supported patients to make decisions. Whereappropriate, they assessed and recorded a patient’smental capacity to make a decision.




Our findingsThe practice is rated as requires improvement forproviding caring services.

Kindness, respect and compassion

From what we saw on inspection and the feedback fromstaff and patients on the inspection staff treated patientswith kindness, respect and compassion. However nationalpatient survey scores were lower than local and nationalaverages in some respects.

• Staff understood patients’ personal, cultural, social andreligious needs.

• The practice gave patients timely support andinformation.

• Reception staff knew that if patients wanted to discusssensitive issues or appeared distressed they could offerthem a private area to discuss their needs.

• All of the 27 patient Care Quality Commission commentcards we received were positive about the care providedand said that clinicians provided compassionate care.Five comment cards contained mixed feedback and onecard only negative feedback. Negative feedback relatedto waiting times for appointments.

Results from the July 2017 annual national GP patientsurvey showed patients rated the practice below local andnational averages for scores related to consultations withGPs. Three hundred and sixty surveys were sent out and110 were returned. This represented about 2% of thepractice population. The practice was below average for itssatisfaction scores on consultations with GPs and nurses.For example:

• 75% of patients who responded said the GP was good atlistening to them compared with the clinicalcommissioning group (CCG) average of 86% and thenational average of 89%.

• 71% of patients who responded said the GP gave themenough time; CCG - 82%; national average - 86%.

• 86% of patients who responded said they hadconfidence and trust in the last GP they saw; CCG - 94%;national average - 95%.

• 63% of patients who responded said the last GP theyspoke to was good at treating them with care andconcern; CCG– 82%; national average - 86%.

• 86% of patients who responded said the nurse wasgood at listening to them; (CCG) - 85%; national average- 91%.

• 93% of patients who responded said the nurse gavethem enough time; CCG - 87%; national average - 92%.

• 82% of patients who responded said they hadconfidence and trust in the last nurse they saw; CCG -94%; national average - 97%.

• 85% of patients who responded said the last nurse theyspoke to was good at treating them with care andconcern; CCG - 85%; national average - 91%.

• 58% of patients who responded said they found thereceptionists at the practice helpful; CCG - 85%; nationalaverage - 87%.

The practice attributed the lower than average scores to alack of clinical time. It was hoped that having recentlytaken on a long term locum would improve access andenable clinicians to build rapport with patients. Thepractice had introduced telephone consultations whichthey hoped would improve GP access and continuity.

In order to address lower than average satisfaction withreception staff the practice told us that they had updatedjob descriptions with a set of competencies that every staffmember would now be working to, staff would hold regularreception meetings and staff would have customer caretraining. However, we could not locate job descriptions forstaff whose files we reviewed and there were no minutesfrom meetings of reception staff.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about theircare.

• Interpretation services were available for patients whodid not have English as a first language. However, therewere no notices in the reception areas, including inlanguages other than English, informing patients thisservice was available. Patients were also told aboutmulti-lingual staff who might be able to support them.Practice staff spoke French, Spanish, Italian, Polish,Hindi and Urdu.

• Staff communicated with patients in a way that theycould understand, for example, communication aidsand easy read materials were available. The practice didnot have a hearing loop but told us that they wouldpurchase one with the money from a recently obtainedimprovement grant.

Are services caring?



• Staff helped patients and their carers find furtherinformation and access community and advocacyservices. The practice had trained a number of receptionstaff as primary care navigators who could refervulnerable patients or those with caring responsibilitiesto local advocacy and support services.

The practice’s computer system alerted GPs if a patient wasalso a carer. The practice had identified 81 patients ascarers (2% of the practice list). Staff told us that if familieshad experienced bereavement, their usual GP contactedthem or sent them a sympathy card or letter. This waseither followed by a patient consultation at a flexible timeand location to meet the family’s needs or a referral to alocal support service. The practice has trained twomembers of reception staff as primary care navigators whocould direct patients to local charities and services forbereavement support.However there was no informationabout local bereavement services in the waiting area.

Results from the national GP patient survey showedpatients’ responses to questions about their involvement inplanning and making decisions about their care andtreatment were lower than other practices locally andnationally in respect of GP consultations:

• 72% of patients who responded said the last GP theysaw was good at explaining tests and treatmentscompared with the clinical commissioning group (CCG)average of 83% and the national average of 86%.

• 63% of patients who responded said the last GP theysaw was good at involving them in decisions about theircare; CCG - 77%; national average - 82%.

• 90% of patients who responded said the last nurse theysaw was good at explaining tests and treatments; CCG -84%; national average - 90%.

• 79% of patients who responded said the last nurse theysaw was good at involving them in decisions about theircare; CCG - 79%; national average - 85%.

Privacy and dignity

The practice respected and promoted patients’ privacy anddignity.

• Staff recognised the importance of patients’ dignity andrespect.

• The practice complied with the Data Protection Act1998.

Are services caring?



Our findingsWe rated the practice, and all of the populationgroups, as requires improvement for providingresponsive services.

Responding to and meeting people’s needs

The practice organised and delivered services to meetpatients’ needs. However the premises were not easilyaccessible in some areas for patients who used awheelchair and there were no designated baby changingfacilities.

• The practice had taken action in response to feedbackfrom its population and tailored services in response tothose needs. (For example extended opening hours,online services such as repeat prescription requests,advanced booking of appointments, advice services forcommon ailments.) Patient survey results indicated thatsome patients were dissatisfied with access.

• There were no baby changing facilities in the practiceand patients would be directed to a free consultationroom to change their baby if one was available. Thecorridor to access clinical rooms was narrow but wewere told that this was wheelchair accessible. However,there were no disabled toilets and the patient toilets didnot appear to be accessible to those with mobilityneeds. The practice were aware of these issues and hadobtained an improvement grant to upgrade thepremises but was waiting for clarification about thefuture of the premises before instigating improvementwork.

• The practice had facilities to deliver care and treatmentbut the premises were not appropriate for the servicesdelivered. For example the practice provided enhancedservices for violent patients. This service was previousheld at another location. We were told that the practicenow had to accommodate these patients on thepremises. The reception area could be accessed easilyby patients if desired. We asked staff about this andwere told that none of the patients treated under thiscontract had attempted to access reception.

• Care and treatment for patients with multiple long-termconditions and patients approaching the end of life wascoordinated with other services.

Older people:

• All patients had a named GP who supported them inwhatever setting they lived.

• The practice was responsive to the needs of olderpatients, and offered home visits and urgentappointments for those with enhanced needs. The GPand practice nurse also accommodated home visits forthose who had difficulties getting to the practice.

People with long-term conditions:

• Patients with a long-term condition received an annualreview to check their health and medicines needs werebeing appropriately met. Multiple conditions werereviewed at one appointment, and consultation timeswere flexible to meet each patient’s specific needs.

• The practice held regular meetings with the local districtnursing team to discuss and manage the needs ofpatients with complex medical issues.

Families, children and young people:

• Although we found deficiencies in the practice’ssafeguarding procedures we did see examples wherechildren living in disadvantaged circumstances whowere at risk were referred to social services.

• The practice could refer patients to the local primarycare extended access service which was open between8 am and 8 pm seven days per week.

• The practice hosted midwives at the practice everyTuesday.

• All parents or guardians calling with concerns about achild under the age of 18 were offered a same dayappointment when necessary.

Working age people (including those recently retired andstudents):

• The practice opened at 7.30am Monday to Friday andclosed at 8 pm on Mondays and Tuesdays.Appointments were available late Monday and Tuesdayand early on a Friday. However, the earliest nursingappointment was 10.30 am on a Friday. Although lateappointments were available until 7.10 pm on Mondaysand Tuesdays. Patients could be booked into the localextended primary care extended access centre whichoffered appointments from 8 am to 8 pm seven days aweek.

• The practice provided fast track registrations to studentsfrom a local university.

Are services responsive to people’s needs?(for example, to feedback?)



• Telephone consultations were available whichsupported patients who were unable to attend thepractice during normal working hours. The practiceprovided online appointments and prescribing and 45%of their patients were signed up to this service.

People whose circumstances make them vulnerable:

• The practice held a register of patients living invulnerable circumstances including those with alearning disability. Eleven of the 21 patients on thepractice’s learning disability register had received alearning disability check. We were told by the practicenurse of a patient with learning disabilities who wasunable to verbalise. As a result they had createdflashcards to enable the patient to express how theywere feeling during the consultation.

• The practice was signed up to an enhanced service forviolent patients who had been removed from otherpractice registers. These patients were accommodatedon a Tuesday afternoon.

People experiencing poor mental health (including peoplewith dementia):

• Staff interviewed had a good understanding of how tosupport patients with mental health needs and thosepatients living with dementia.

• The practice had connections to a local charity whichaimed to bring people together to tackle social isolationand improve the mental wellbeing of people living in thecommunity.

• The practice referred patients to a local counsellingservice and hosted a private counsellor twice weekly.

Timely access to the service

Most of the patients we spoke with on day told us that theywere able to access care and treatment from the practicewithin an acceptable timescale for their needs. However,national patient survey scores rated the practice lower thanthe national average in respect of access.

Feedback from patients indicated that:

• Patients had timely access to initial assessment, testresults, diagnosis and treatment.

• Delays and cancellations were minimal and managedappropriately. Though some patients said that waitingtimes could be in excess of 15 minutes.

• Patients with the most urgent needs had their care andtreatment prioritised.

• The appointment system was easy to use.

However, results from the July 2017 annual national GPpatient survey showed that patients’ satisfaction with howthey could access care and treatment was below local andnational averages. This contrasted with our observationson the day of inspection and the completed commentcards received. Three hundred and sixty surveys were sentout and 110 were returned. This represented about 2% ofthe practice population.

• 65% of patients who responded were satisfied with thepractice’s opening hours compared with the clinicalcommissioning group (CCG) average of 77% and thenational average of 80%.

• 63% of patients who responded said they could getthrough easily to the practice by phone; CCG – 75%;national average - 71%.

• 56% of patients who responded said that the last timethey wanted to speak to a GP or nurse they were able toget an appointment; CCG - 73%; national average - 75%.

• 65% of patients who responded said their lastappointment was convenient; CCG - 75%; nationalaverage - 81%.

• 46% of patients who responded described theirexperience of making an appointment as good; CCG -69%; national average - 73%.

• 34% of patients who responded said they don’tnormally have to wait too long to be seen; CCG - 51%;national average - 58%.

The practice provided us with information on action takento try to improve patient satisfaction with access. Thepractice opened from 7.30 am every day and a newtelephone system had been introduced increasing thenumber of lines and directing patients to call at differenttimes for test results in an effort to ease congestion. Theypromoted alternative services including online access andpharmacy first. A new triaging appointment system andtelephone consultations had been introduced to allowbetter use of face to face appointments and the practicehad employed an additional GP on Monday and Tuesdaymornings.

The practice had also introduced 10 minute ‘catch up’ slotsfor every three regular GP appointments and textreminders for appointments advising patients to bookdouble appointments if they had more than one issuewhich needed to be discussed.




Listening and learning from concerns and complaints

The system in place to handle complaints was not effective.There was not clear leadership and oversight in this areaand the practice was unable to produce any responsesgiven to complaints.

• Information about how to make a complaint or raiseconcerns was available on a notice board in thereception area and on the practice website, though takeaway copies needed to be requested from receptionstaff.

• The lead noted in the complaint policy was not theperson accepted by most staff as the person responsiblefor complaints. Three complaints were received in thelast year. We saw evidence of acknowledgement butstaff could not provide us with any responses. Thecomplaint lead told that the process was confused anddid not operate effectively.




Our findingsThe practice is rated as inadequate for providingservices that were well led.

Leadership capacity and capability

Leadership in the practice was fragmented and did notoperate effectively.

• Management responsibilities were split between variousmembers of staff. Staff who led in key areas were notfully aware of their responsibilities or how thingsoperated. Some staff were unaware of which staffmember led in certain areas and feedback from staffcontradicted documented information on leadershipwithin practice policies.

• Issues around the premises had created uncertaintyregarding the future viability of the practice and we weretold that this was one of the reasons that the practicehad delayed decisions related to future staffingincluding employing a new practice manager.

• The practice manager only attended the practice twice amonth and most staff we spoke with did not know whatrole the practice manager performed.

• Some staff did not have capacity to takle on the fullrange of responsibilities due to having limited capacityas a result of the workload stemming from their areas ofprimary responsibility.

Vision and strategy

The practice had an overarching vision regarding the futuredirection of the practice but it was evident that the lack ofeffective leadership and governance impacted on thepractice’s ability to implement strategic goals, deliver highquality care and promote good outcomes for patients.

• There was a lack of clear vision. Although the practiceaimed to become a partnership and makeimprovements to the premises, we were told that theirability to plan for the future had been hindered byuncertainty around the premises. The practice hadproduced a document in June 2017 which aimed toidentify efficiencies. It was evident from reviewing thedocument that the practice was aware of the challengesthey faced and areas where improvement was required.For example the report stated that no one wasresponsible for CQC policies and procedures. Severalstaff were noted as potentially taking on this

responsibility including a new practice manager or thepractice nurse. However, there was no clear plan inplace to address the issues identified and there was noevidence of the plan having been subsequentlyreviewed.

• We saw evidence that patients had been consulted onchanges within the practice including the appointmentsystems. The efficiency review indicated that a broadrange of staff were involved in discussions around thefuture direction of the practice.

Culture

The practice encouraged staff to be open and honest but insome respect support was insufficient. For example, therewas no documented evidence of internal appraisal, and alack of managerial support meant that some staff wereoverburdened.

• Staff stated they felt respected and valued and most feltsupported in their day to day working. However, somestaff told us that managerial support was lacking. Wewere told by staff that the absence of a permanentpractice manager working on site had put additionalpressure on other staff members and there was a lack ofclarity as to who was responsible for what.

• It was unclear how performance of staff would bemanaged.

• The provider was aware the duty of candour and gavean example which demonstrated compliance with theduty. However, the systems in place to ensurecompliance were ineffective. We saw no responses tocomplaints and there was no formalised policy in placefor the management of significant events.

• Staff we spoke with told us they were able to raiseconcerns and were encouraged to do so. They hadconfidence that these would be addressed.

• We were told by a member of staff employed via thefederation, who provided support with IT and QOF, thatall staff had received an appraisal within the last twelvemonths but they confirmed that there was no paperwork as these had not been written up. Two members ofstaff we spoke with stated that their appraisal was dueand were uncertain when their last appraisal had been.Staff were supported to meet the requirements ofprofessional revalidation where necessary.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



• Clinical staff, including nurses, were considered valuedmembers of the practice team. They were givenprotected time for professional development andevaluation of their clinical work.

• Lack of effective oversight of risk, leadership andgovernance generally put staff at risk; particularly inrespect of fire safety and infection control.

• There were positive relationships between staff andteams.

Governance arrangements

There was a lack of clarity around key areas ofresponsibility and accountability. Governance systems didnot operate effectively. Policies lacked clarity, were notpractice specific and contained inaccurate information.

• Structures, processes and systems did not support goodgovernance and management was lacking in key areasincluding complaints, significant events and infectioncontrol. Staff were often unclear on their roles and inthese areas.

• Policies were not tailored to the specific needs of thepractice; for example, the practice’s adult safeguardingpolicy was from another service. We were provided witha practice specific policy after the inspection but this didnot detail the practice lead. Some policies were notpresent at all; for example, there was no fire safetypolicy. The governance framework was not effective. Forexample there was little evidence of risk managementand the procedures for managing complaints wasdisorganised and confusing.

Managing risks, issues and performance

Systems to manage risks, issues and performance wereabsent or insufficient.

• There were few processes in place to identify,understand, monitor and address current and futurerisks including risks to patient safety. For example therewas little in place to mitigate risks associated with fireand no evaluation of risks associated with infectioncontrol.

• The practice did not have processes to manage currentand future performance. Consultations and referraldecisions were not audited although we some examplesof prescribing reviews. Practice leaders lacked oversightof MHRA alerts and complaints.

• Clinical audit had limited positive impact on quality ofcare and outcomes for patients. There was evidence ofaction to change practice to improve quality.

• The practice had plans in place for major incidentsthough some staff had not completed basic life supporttraining within the last 12 months.

Appropriate and accurate information

The practice had access to appropriate and accurateinformation. However, there was no evidence of internalclinical meetings where the quality of patient care wasreviewed and discussed and the practice had not takenaction to address some areas of poor clinical performance.

• There was limited evidence that the practice used datato plan how to improve areas of weaker performance.For example, while the practice were able to providereasons why they thought that uptake of cervicalscreening and immunisations was low there was noplan in place to improve patient engagement in theseareas.

• We saw no evidence of quality being discussed atmeetings. We were told that meetings were held everyMonday. Staff said that notes had been taken formeetings but not written up. The last set of notes wecould find from an internal practice meeting were fromJanuary 2016.

• The information used to monitor performance and thedeliver care was accurate and useful.

• The practice submitted data or notifications to externalorganisations as required.

• There were robust arrangements for the availability,integrity and confidentiality of patient identifiable data,records and data management systems.

Engagement with patients, the public, staff andexternal partners

The practice took into account feedback from patients andstaff.

• A range of patients’, staff and external partners’ viewsand concerns were encouraged, heard and acted on toshape services and culture.

• There was an active patient participation group. Thepractice hosted a dermatologist and invited patients toattend a presentation about skin health.

• The service was transparent, collaborative and openwith stakeholders about performance including thelocal federation.




Continuous improvement and innovation

We saw some examples of innovative practice.

• The practice nurse had created a template for travelimmunisations together with support from a colleaguewithin the federation. This provided prompts to ensurethat nursing staff asked and recorded all pertinentinformation before administering travel immunisations.

This was supported by a travel pack that the nurse hadproduced. We also saw that the nurse had created apack for pre diabetic patients with advice on diet andlinks to other sources of information.

• The practice nurse had introduced relaxation sessionswhich aimed to relax patients who had anxieties aboutinvasive procedures stemming from previous trauma.This involved playing relaxing music, using breathingtechniques and giving patients equipment that theycould practice with so they knew what to expect whenthey attended for certain examinations or procedures.




Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Maternity and midwifery services

Treatment of disease, disorder or injury

Regulation 13 HSCA (RA) Regulations 2014 Safeguardingservice users from abuse and improper treatment

How the regulation was not being met:

Systems and processes had not been established toprevent abuse of service users as the practice’ssafeguarding policies were not customised to thepractice’s needs and staff were not chaperoning inaccordance with best practice.

This was in breach of regulation 13(2) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.




Regulation 18 HSCA (RA) Regulations 2014 Staffing


There were not sufficient numbers of suitably qualifiedstaff employed to ensure adequate nursing provisionand managerial oversight. Not all staff had received therequired essential training including safeguarding,information governance and basic life support training inaccordance with current legislation and guidance.

This was in breach of regulation 18 (1) (2) (a) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014.

Regulation

Regulation

This section is primarily information for the provider

Requirement notices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.




Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Warning notice


The registered person did not do all that was reasonablypracticable to assess, monitor, manage and mitigaterisks to the health and safety of patients who useservices. They had not assessed risks associated withfire, legionella, infection control, patient safety alerts,the management of medicines, emergency procedure,urgent referrals and recruitment.

This was in breach of regulation 12(1) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014




Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Warning notice


The registered person did not do all that was reasonablypracticable to assess, monitor, manage and mitigaterisks to the health and safety of patients who useservices. There was a lack of effective policiesprocedures and governance to enable effectivemanagement of risks associated with fire, legionella,infection control, patient safety alerts, the managementof medicines, emergency procedure, urgent referrals andrecruitment. There was a lack of effective systems inplace to monitor staff training and appraisal and noaction plan in place to address areas of clinical

Regulation

Regulation


Enforcement actions


performance which was below local national averagesand there were no documented internal meetings fromthe last 12 months. The systems for managingcomplaints and significant events and. governancearrangements around chaperoning and safeguardingwere not effective.

This was in breach of regulation 17(1) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014


Enforcement actions


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